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DISEASE
HNI 455
Cardiac Output
The amount of blood ejected from the
heart in one minute. (4-8 L/min)
CO=SV X HR
Stroke volume is the amount of blood
pumped with each contraction
Hemodynamic
monitoring
Special indwelling catheters that
provide information about blood volume
and perfusion, fluid status and how well
the heart is pumping.
Central
Atherosclerotic
Progression
3 stages of atherosclerotic
plaque development
Fatty streaks earliest lesions age 15.
LDL lowering agents may reverse.
Fibrous plaque phase endothelial
damage cholesterol deposition in intima
Complicated lesion stage continuation of
inflammation leads to an unstable plaque
lesion. Rupture platelets thrombus!
Hemodynamic effects of
CAD
Disturbance in the delicate balance between
myocardial oxygen supply and demand
Vessels become stiff and lose ability to dilate
Decreased O2 is supplied to myocardium;
resulting in tissue hypoxia or ischemia
Treatment of CAD
HEALTH PROMOTION** IDENTIFY
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ASSESS WHEN READY TO LEARN!
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PAGE 768
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3 Manifestations of CAD
Angina - symptoms when 70% occluded
Stable Angina
Unstable angina Acute coronary syndrome, preinfarction
angina
Silent ischemia
M.I.
Sudden cardiac death
Types of Angina
Stable angina (exertional angina) Lack of O2 is temporary
and reversible. Predictable, usually occurs with exertion.
Unstable angina Acute coronary syndrome or ACS more prolonged lack of O2, unpredictable and represents
an emergency, occurs during rest, sleep and increasing
frequency.
Variant Prinzmetalss angina coronary spasm
Atypical Women Fatigue, SOB, indigestion and anxiety.
Acute Coronary
Syndrome
Because unstable angina and acute MI
are considered to be the same process
but different points along a continuum
The term Acute coronary syndrome
(ACS) is used.
Pain unrelieved by rest or nitroglycerin
and lasting for more than 15 min
differentiates MI from angina.
Manifestations of ACS
Chest pain that is new in onset, occurs at rest
or has a worsening pattern is called unstable
angina.
As the cells are deprived of O2, ischemia
develops, cellular injury occurs, and the lack
of O2 results in infarction or the death of cells.
Myocardial infarction (MI).
MI is associated with nausea, epigastric
distress, dyspnea, anxiety, diaphoresis
SLIDTA Assessment of
Angina
S 1-10 scale
L Where is the pain and where does it go? Substernal
radiating to neck and jaw, left shoulder and down both
arms, epigastric radiating to neck, jaw and arms.
I What initiated and relieved? Argument, exercise, resting
and what relieved? Sitting down, NTG
D How long? Have you had pain like this before?
T What does it feel like? Pressure, dull, aching, tight,
squeezing, heaviness
A Other symptoms? diaphoresis, nausea, vomiting,
anxiety, feeling of doom. Women?
Pathophysiology
Ischemia occurs within 20 minutes;
necrosis occurs within 6 hours.
Time is muscle!!
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3.
Myocardial Infarction
Chest pain unrelieved by rest and NTG
Deficiency of coronary artery blood supply
resulting in NECROSIS of myocardial tissue
25 % die before reaching hospital
Eighty to 90% of all acute MIs are secondary to
thrombus formation Interventions (emergent
PCIs or fibrinolytic therapy) have greatly reduced
mortality rates.
Anatomical Location of
MI
Inferior wall RCA; also perfuses SA node
and conduction system look for
conduction disturbances
Lateral wall left circumflex -LCX
Anterior wall - LAD; large portion of LV;
look for problems with mechanical pumping
ability of heart
Assessment and
Diagnostic Findings of MI
History
Presenting symptoms:
Pain unrelieved by rest and NTG (described as
severe and immobilizing, heaviness, pressure,
tightness, burning, constriction or crushing.)
Associated symptoms - diaphoresis, nausea,
vomiting
12 lead EKG changes (Q waves, ST elevation or
depression)
Assessment and
Diagnostic Findings of MI
Serum cardiac markers: These tests are based on the
release of cellular contents in the circulation when
myocardial cells die.
Troponin I (marker of choice) norm <0.1mg/ml (rises
4-6 hr, peak 10-24, normalizes 10-14 days)
CK MB (rises 6 hr, peak 18 hr, normalizes 24-36)
Physical Exam can be normal
Complications of MI
Arrhythmias
Acute LV failure (HF)
Cardiogenic shock
CCU
Stepdown unit
Home rehab most patients in our area
Community rehab program
Geriatric considerations
Older adults often do not feel the intense
crushing pain.
Arteries are less elastic, less distensible. Systolic
HTN
CO decreases by 1% per year after age 70
Antianginal agents that cause postural
hypotension and decrease preload may not be
tolerated.
More complications. After MI > afib.
However, they do have well established
collaterals
ANEURYSMS and
VASCULAR DISEASE
HNI 455
Professor Patricia Voelpel
Revised 2014
THORACIC ANEURYSM
Secondary to atherosclerosis
Men ages 40-70
Most common site for dissection
Pain is prominent symptom
Dyspnea, cough, hoarseness, and
dysphagia
Surgically repaired
ABDOMINAL AORTIC
ANEURYSM (A.K.A. AAA)
Secondary to atherosclerosis
More common in Caucasians
Men >60 yoa
Complain they can feel their heart
beating in their abdomen
80 % are palpable with bruit over mass
Surgically repaired
ARTERIAL OCCLUSIVE
DISEASE
Arterial vs Venous
Disease
Arterial
Venous
Pulses
Weak, thready
Bounding
Color
Pale, mottled
Red
Temperature
Cool
Warm
Optimal Positioning
Dependent
Elevated
DIAGNOSTICS
Doppler studies
Angiography
Thrombolytics
Exercise testing
DEEP VEIN
THROMBOSIS
Symptoms are edema, swelling of the
extremity because outflow of blood is
obstructed, can be warm and tender
Management